Surgical management of monocular torsion and head tilt after macular translocation

BACKGROUND: Macular translocation following 360 degrees retinotomy is a possible surgical treatment of patients with age-related macular degeneration. However, it produces important subjective disturbances with diplopia and head tilt due to cyclodeviation. Complex surgical procedures involving both oblique muscles and two or four recti have been advocated. PATIENTS AND METHODS: Four symptomatic patients with macular translocation underwent counter-rotating surgery by very large recession and advancement of both oblique muscles of the affected eye. Preoperative subjective cyclo-deviations varied between 25 degrees and 60 degrees and head tilt ranged between 25 degrees and 45 degrees . RESULTS: Reduction of cyclodeviation ranged between 22 degrees ant 30 degrees in our four patients. Two patients showed residual cyclo-deviations of 3 degrees and 7 degrees with complete recovery of the head tilt. The remaining two patients showed significant subjective improvements and important reductions of head tilt, in spite of a large residual cyclodeviation. No patient exhibited binocular vision. CONCLUSION: Without jeopardizing the anterior segment blood supply of these elderly patients, a combined surgical procedure on both oblique muscles has shown to be sufficiently effective in reducing subjective cyclodeviation and head tilt in four cases of macular translocation. A complete counter-rotation does not seem to be required to achieve an important improvement of subjective symptoms. This may be due to sensorial adaptation.     

Management of ocular torsion and diplopia after macular translocation for age-related macular degeneration: prospective clinical study

Purpose

To report the results of a prospective clinical series to evaluate the management of both torsion and diplopia in a large group of patients after full macular translocation (FMT) and extraocular muscle surgery.

Design

Prospective interventional case series.

Methods

Information gathered included demographic, visual acuity, ocular motility, torsion by Maddox rod, ocular history, and symptoms of visual disturbance. Surgery on two, three, or four extraocular muscles was performed based on the magnitude of torsion measured after FMT surgery.

Results

Fifty-three patients were included for both objective and subjective outcomes and were evaluated after FMT, both before (preoperative) and after (postoperative) extraocular muscle surgery. Preoperative torsion for two- (n = 6), three- (n = 8), and four-muscle (n = 39) surgery groups was 21.2 ± 4.6, 30.0 ± 6.3, and 40.5 ± 8.7 degrees, respectively. At 6 months, postoperative residual torsion was significantly reduced in each group (to 3.4 ± 3.2, 5.6 ± 5.5, and 4.5 ± 6.8 degrees, respectively, for two-, three-, and four-muscle groups). Muscle surgery reduced mean hypertropia from 17 ± 6 prism diopters preoperative to 4 ± 10 prism diopters postoperative (P < .0001); mean exotropia was mildly reduced from 20 ± 9 prism diopters preoperative to 13 ± 11 prism diopters postoperative (P < .01). Subjective data regarding diplopia and tilted vision after FMT and muscle surgery were available on an additional 10 patients (n = 53 + 10 = 63). Overall, 41% (26/63) of these were free of both diplopia and tilt, whereas only 5% (3/63) had both symptoms constantly.

Conclusions

Extraocular muscle surgery is effective at relieving the variable amounts of torsion produced by FMT when graded to match preoperative torsion. The majority of patients were free of disabling tilt and diplopia after extraocular muscle surgery.     

Strabismus surgery after macular translocation

PURPOSE: To present the application of various extraocular muscle surgery techniques to eliminate incyclotorsion induced by macular translocation. MATERIAL AND METHODS: Authors present surgical options and present the case of the patient in whom macular translocation was performed in Tübingen (Germany). Afterwards five strabismological surgeries were done: 2 in Tübingen and 3 in Department of Strabismology, Cracow District Eye Hospital. RESULTS: At the end of strabismological treatment the patient was free of disabling image tilt and diplopia. CONCLUSIONS: We present this case as an announcement of future challenge for strabologists if macular translocation surgeries will be performed in Poland.     

Measurement of ocular torsion after macular translocation: disc fovea angle and Maddox rod.

PURPOSE: To compare two methods of measuring ocular torsion (the subjective Maddox rod [MR] test versus the objective disc-fovea angle [DFA] test) after macular translocation surgery. METHODS: Ocular torsion was measured on consecutive patients after macular translocation at Duke University Eye Center between August 2001 and April 2002. Both MR and DFA measurements of torsion were made at the same clinic visit 4 to 8 weeks after the translocation surgery and again within 3 months after extraocular muscle surgery to decrease torsion. MR and DFA measurements were each performed by a separate examiner who was blinded to the results of the other method. RESULTS: Thirty-five patients (35 eyes) were included for evaluation. Twenty-nine of these patients had intorsion measured by both MR and DFA after macular translocation but before extraocular muscle surgery (MR mean of 40.3 + 7.2 degrees v DFA mean of 47.0 + 7.9 degrees [P <.001]). The intrapatient reproducibility of the MR test was high (using four readings per session), with a mean coefficient variation of 4.8%. Twenty-five patients had residual torsion measured by both MR and DFA after extraocular muscle surgery (MR mean of 4.2 + 4.7 degrees v DFA of mean 4.8 + 7.0 degrees). There was good correlation between MR and DFA measurements of torsion (r(2) = 0.9). CONCLUSIONS: DFA measurement correlates well with MR measurement of torsion in patients after full macular translocation. This study verifies the reproducibility of MR to measure large angles of torsion and offers DFA as a simple corroborative test for measuring ocular torsion in patients with poor vision or cooperation.     

Diplopia after limited macular translocation surgery

PURPOSE: Full macular translocation surgery relocates the fovea away from choroidal neovascularization, inducing significant postoperative torsional diplopia. In "limited macular translocation," a saline-induced retinal detachment is followed by scleral imbrication with mattress sutures and spontaneous retinal reattachment. In this study, diplopia was characterized in patients treated with limited macular translocation. METHODS: Two surgeons performed retinal translocation surgery on 250 patients over an 18-month time span. The extent and direction of the retinal translocation, and the amount and location of scleral imbrication, were recorded. All patients complaining of diplopia were referred for ocular motility evaluation and treatment. RESULTS: Thirteen (5.2%) patients complained of occasional or constant diplopia. Imbricating sutures were placed supero-temporally in all cases. Inferior foveal translocation ranged from 200 to 2115 microm (median, 1750 microm). Visual acuity ranged from 20/40 to 20/400 in the operated eye. Prism-and-cover testing underestimated the strabismus when compared with subjective testing. In 3 patients, there was no shift on alternate-cover testing despite binocular diplopia. Excyclotorsion ranged from 0 degrees to 16 degrees. Diplopia resolved in 10 cases with prism; 3 required an occlusive filter for distortion or aniseikonia. One patient underwent successful strabismus surgery to eliminate dependence on prism glasses. CONCLUSIONS: Limited macular translocation only rarely produces symptomatic diplopia. Suprisingly, traditional prism-and-cover testing does not reliably quantify the misalignment. This may result from the combination of a persistent macular scotoma and a repositioned fovea relative to the peripheral retina. Prism therapy is generally satisfactory in the absence of retinal distortion or aniseikonia.     

Cyclotropia and surgical treatment after macular translocation

PURPOSE: Macular translocation is a new surgical treatment method successfully performed in recent years in cases of age-related macula degeneration. Cyclotropia and associated orthoptic problems may occur after macular translocations. The aim of our study was to present the application and results of various external eye muscle surgery techniques to eliminate cyclodeviation after macular translocation. METHODS: Between January 2001 and April 2001, 15 patients underwent macular translocation. After an average of 47 days counterrotation was applied to these patients to eliminate incyclotropia formed due to macular translocation. In 8 cases, superior and inferior oblique muscle surgery was combined with opposite vertical transpositions of the horizontal recti. In 5 cases, full tendon transposition of the superior oblique muscle to the nasal part of the globe was combined with the anterior margin advancement of the inferior oblique muscle. In 2 cases, only combined surgery of superior and inferior oblique muscles was performed. The degree of cyclodeviation was measured by both objective and subjective methods before and after counterrotation. Mean follow-up period was 53.9 days. RESULTS: The average objective cyclodeviation formed after macular translocation was 29.6 degrees. Combined surgery of superior and inferior oblique muscles led to a mean excyclorotation of 15 degrees whereas combined oblique muscle surgery performed with vertical transposition of horizontal recti provided a mean excylorotation of 20.8 degrees. The most effective method was the combination of total nasal transposition of superior oblique muscle with the anterior margin advancement of the inferior oblique muscle resulting in an improvement by 33 degrees. CONCLUSIONS: Macular translocations cause cyclodeviation. The ensuing cyclotropia can be eliminated by various surgical techniques of external eye muscles according to the degree of cyclotropia.     

Changes in focal macular ERGs after macular translocation surgery with 360 degrees retinotomy

PURPOSE: To evaluate the short- and long-term changes of focal macular electroretinograms (fmERGs) after macular translocation with 360 degrees retinotomy. METHODS: This was a retrospective study. fmERGs were recorded in 19 eyes of 19 consecutive patients who underwent macular translocation with 360 degrees retinotomy for choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD; 17 eyes) or polypoidal choroidal vasculopathy (2 eyes). The changes in the fmERGs, recorded before, shortly after (6-12 months; mean 8.3 months), and more than 18 months (18-30 months; mean 22.4 months) after surgery from 12 eyes, were analyzed. A 15 degrees stimulus centered on the fovea was used to elicit the fmERGs. RESULTS: The mean logarithm of minimum angle of resolution (logMAR) was 1.06 +/- 0.07 (20/230) before surgery, 0.78 +/- 0.08 (20/121) early after surgery (n = 19), and 0.64 +/- 0.07 (20/87) late after surgery (n = 12). These improvements in visual acuity were significant (P = 0.0074, P = 0.0050, respectively). Before surgery, the amplitudes of all components of the fmERGs were markedly reduced in all eyes. The mean b-wave amplitude in 17 AMD eyes recorded early after surgery was significantly larger (P = 0.0262), and the mean a-wave amplitude was also increased but not significantly (P = 0.1180). The mean amplitudes of the a- and b-waves in 10 AMD eyes recorded after 18 months were significantly larger than those before the surgery (P = 0.0218, and P = 0.0284). The mean implicit time of the b-wave in 17 AMD eyes decreased early after surgery, and a further decrease was detected at the later testing time. CONCLUSIONS: These results indicate that macular function is partially recoverable after macular translocation in some patients.     

Results of compensatory extraocular muscle surgery after macular translocation

PURPOSE: Macular translocation is an optional surgical treatment for age-related macular degeneration. However, this technique induces postoperative torsional complaints and surgical counterrotation of the globe is mandatory. The purpose of this study is to report the effect of compensatory extraocular muscle surgery upon the torsional complaints in patients who underwent a macular translocation procedure. DESIGN: The pre- and postoperative data on the first 35 patients in our department who underwent a counterrotation procedure after macular translocation surgery are reviewed. METHODS: From November 2001 to January 2005, 35 patients underwent a macular translocation procedure, with subsequent extraocular muscle surgery to counterrotate the eye. Three types of rectus muscle transposition procedures were used: full-tendon transposition of two opposite rectus muscles, "crossed" half-tendon transposition of all rectus muscles ('split & cross' procedure), and "uncrossed" half-tendon transposition of all rectus muscles ('split & neighbor cross' procedure). In the majority of patients these procedures were associated with oblique muscle surgery. RESULTS: With the selected procedures, retinal excyclodeviations are easier to correct then retinal incyclodeviations. In our hands, full-tendon transposition of two opposite rectus muscles with or without associated oblique muscle surgery, never corrects more than 30 degrees. 'Split & cross' procedures combined with oblique muscle surgery are sufficient for retinal excyclodeviations of 30-45 degrees and for incyclodeviations of up to 30 degrees; 'split & neighbor cross' procedures combined with oblique muscle surgery are sufficient for retinal excyclodeviations of 45-65 degrees and for incyclodeviations of up to 40 degrees . CONCLUSIONS: The effect of the various procedures appears to be predictable. It is possible to select a surgical procedure as a function of the amount of retinal cyclodeviation.     

Progression of choroidal neovascularization after macular translocation in age-related macular degeneration and degenerative myopia

PURPOSE: To study the progression of choroidal neovascularization (CNV) after macular translocation in age-related macular degeneration (AMD) and degenerative myopia. PATIENTS AND METHODS: The data from 42 consecutive eyes (28 AMD, and 14 degenerative myopia) operated on by limited macular translocation (DeJuan technique), with a follow-up of 6 months or more, were prospectively analyzed. In the AMD group, neovascularization was classic in 54% of eyes and classic and occult in 46% of eyes. Previous laser treatment was applied on extra- or juxtafoveal CNV in 3 eyes. The major outcome measures were visual acuity, fluorescein and indocyanine green angiographies. RESULTS: After translocation, foveal displacement was greater in AMD than in myopic eyes (mean: 1 260 and 812 micro m, respectively). Laser photocoagulation was applied postoperatively onto extra-or juxtafoveal CNV in 26 (93%) AMD eyes and 12 myopic eyes (86%). Mean follow-up was 10 months (range, 6-18 months). Recurrence of CNV occurred in 14 AMD eyes (50%) and 2 myopic eyes (14%) an average of 5.6 months after surgery (range, 1-18 months). Recurrence was more frequent in AMD eyes with preoperative occult CNV (66%) than without (36%). Recurrence reached the new fovea in 69% of cases. Supplementary laser treatment was possible and successful on extra- or juxtafoveal recurrence in 3 eyes. Recurrence was significantly correlated with a poor visual prognosis: eyes without recurrence or with extra- or juxtafoveal recurrence had a final gain in visual acuity of 2.4 lines, eyes with subfoveal recurrence had a loss of 1.3 lines, and eyes with diffuse recurrence had a loss of 4.2 lines. CNV appeared in a new area at a BSS injection site in one eye. Occult CNV seemed to fade relatively within the first postoperative weeks, but were unchanged at the end of follow-up. In one eye, a small polypoidal lesion near the disc noted preoperatively disappeared after surgery. CONCLUSION: Our results suggest that the surgical procedure does not affect the course of classic or occult CNV. The rate of recurrence of CNV after macular translocation seemed similar to that observed after conventional laser treatment for extrafoveal CNV in AMD. Neovascular recurrence is the most frequent postoperative complication and was frequently directed at the new fovea. Despite these complications, macular translocation moves CNV outside of the subfoveolar zone so the eyes can be treated with conventional laser, leading to a favorable outcome at the last follow-up in 57% of cases. Further studies are required to confirm these findings and to define the best criteria for treatment.     

Strabismus surgery for large-angle cyclotorsion after macular translocation surgery.

PURPOSE: We report the results of a new strabismus surgical procedure to address the large-angle cyclotorsion induced by macular translocation surgery for severe age-related macular degeneration. METHODS: The strabismus surgery described is a modification of earlier-described surgery(1) and was performed for symptomatic incyclotorsion measuring 20 degrees or more (by Maddox rod testing) after macular translocation. Surgery included superior oblique tenotomy and inferior oblique advancement, with transposition of the lateral and medial recti to the insertions of the superior and inferior recti, respectively, in the affected eyes. Minimum follow-up time was 6 weeks. RESULTS: Fifteen patients (15 eyes) had macular translocation surgery with incyclotorsion of 20 degrees or more. Mean incyclotorsion after macular translocation (36.1 +/- 9.4 degrees; range, 20-55) was reduced to 1.5 +/- 6.4 degrees after strabismus surgery (P <.0001), with 2 overcorrections and no surgical complications. Mean follow-up time was 24.8 +/- 13.4 weeks. All patients showed a hypertropia of the fellow eye. The mean pre-op hypertropia of 22 +/- 8 PD was reduced to 3 +/- 9 PD after strabismus surgery (P <.0001). The mean exotropia was minimally altered by strabismus surgery (21 +/- 10 PD pre vs 17 +/- 8 PD postop). All patients were symptomatic prior to strabismus surgery: 4 of 15 patients with "tilt" (objects appearing subjectively rotated with respect to their true orientation); 2 of 15 patients with diplopia; and 9 of 15 patients with both. Postoperatively, 7 patients had residual milder symptoms: tilt, 2 patients; diplopia, 3 patients; and both, 2 patients. Two patients required additional muscle surgery (on the fellow eye) for persistent symptoms. No patient showed binocular function (stereopsis or motor fusion) after macular translocation, either before or following strabismus surgery for cyclotorsion. CONCLUSION: The strabismus surgery described is effective at reducing the large degree of cyclotorsion (>or= 20 degrees) often resulting from macular translocation surgery, but does not allow reestablishment of binocular function.     

Fixation switch and diplopia after full macular translocation surgery.

PURPOSE: We sought to identify and evaluate treatment of patients who switched fixation to the poorer-seeing eye and complained of persistent diplopia 6 to 12 months after full macular translocation surgery (MT360) and extraocular muscle surgery. METHODS: All patients enrolled in a prospective study undergoing MT360 and extraocular muscle surgery were included. All patients had sensorimotor examinations. Visual acuity and fixation preference between 6 and 12 months after MT360 and extraocular muscle surgery were analyzed. RESULTS: Preoperative median visual acuity was 20/100 in operated vs 20/640 in fellow eyes; after MT360, the values were similar to the preoperative values (n = 67). After MT360 but before extraocular muscle surgery, all patients preferred the fellow eye for ambulation. Six to 12 months after MT360, 58 of 67 (86%) patients fixated with the better-seeing eye (52 operated vs 6 fellow eyes); 4/67 (6%) fixated with the operated eye despite its poorer or equal visual acuity; 5 of 67 (8%) fixated with the poorer-seeing fellow eye, all 5 of whom experienced diplopia (ie, fixation switch and diplopia). Treatment of diplopia included Fresnel prism, additional extraocular muscle surgery, and occlusion. CONCLUSIONS: Fixation switch to the poorer-seeing eye can occur after MT360, despite a successful visual outcome in the operated eye and the diplopia is difficult to treat.     

Severe hypotony after macular translocation surgery with 360-degree retinotomy

PURPOSE: To report a case of severe hypotony after macular translocation with 360-degree retinotomy. DESIGN: Interventional case report. METHODS: A 50-year-old woman with myopic neovascular maculopathy underwent macular translocation with 360-degree retinotomy in her left eye. RESULTS: After the second procedure of silicone oil removal, severe hypotony developed. No clear sign of leakage was found. Pure perfluoropropane gas tamponade was then performed, which resulted in temporal resolution of severe hypotony, but the hypotony recurred as the gas bubble was absorbed. Ten weeks after the second surgery, the hypotonous eye was refilled with silicone oil. No apparent cyclitic membrane was observed intraoperatively. After this procedure, the choroidal and retinal folds regressed; intraocular pressure has been between 5 and 7 mm Hg for more than 4 months thereafter. CONCLUSION: Severe hypotony can occur as a complication of otherwise uneventful macular translocation with 360-degree retinotomy.     

Strabological findings after macular translocation surgery with 360 degrees retinotomy

PURPOSE: To examine the strabological findings after macular translocation surgery with a 360 degrees retinotomy. METHODS: Thirty-two patients who underwent macular translocation surgery were divided into three groups based on their responses to the Bagolini striated lenses test: fusion, ignoring the image, and diplopia. The relevant factors affecting binocularity were compared among the three groups. RESULTS: Five patients had peripheral fusion and three of these had gross stereopsis. Fifteen patients ignored the second image, and 12 patients had diplopia. The objective angle of macular rotation was smaller in the patients with peripheral fusion (15.0 +/- 6.1 degrees) than in those with diplopia (32.7 +/- 11.7 degrees). The subjective angle of cyclotorsion in those with peripheral fusion (6.0 +/- 4.2 degrees) was smaller than in those who ignored the image ("ignoring" group; 20.5 +/- 9.19 degrees) and the diplopia group (30.7 +/- 12.8 degrees). The amount of torsional sensory compensation in patients with diplopia (2.08 +/- 3.83 degrees) was significantly smaller than in those with peripheral fusion (9.00 +/- 7.42 degrees) and in the ignoring group (6.73 +/- 3.86 degrees). Patients with peripheral fusion were significantly younger (54.2 +/- 14.3 years) than those in the ignoring group (67.7 +/- 10.0 years) and those with diplopia (68.0 +/- 5.4 years). CONCLUSIONS: Adaptive mechanisms are activated to reduce the surgically induced objective angle of cyclotorsion, and a cyclodeviation of 15 degrees was the critical angle separating those who had peripheral fusion from those who did not. This value corresponds to the cyclofusional amplitude in normal adults.     

Reading ability after macular translocation surgery with 360-degree retinotomy

PURPOSE: To report reading ability using a standardized reading chart after macular translocation with 360-degree retinotomy in eyes with age-related macular degeneration (AMD) or with myopic choroidal neovascularization (mCNV). DESIGN: Interventional case series. METHODS: In 34 eyes of 34 patients with subfoveal choroidal neovascular membrane (AMD, 23; mCNV, 11), macular translocation surgery with 360-degree retinotomy and simultaneous extraocular muscle surgery were performed. The average age was 67.4 +/- 7.9 years, and the average follow-up period was 7.6 +/- 3.3 months. The best-corrected far visual acuity (FVA) was measured with a standardized visual acuity chart using Landolt Cs, and the critical print size (CPS) was determined with the Japanese version of the Minnesota reading chart (MNREAD-J Chart) preoperatively and postoperatively. Preoperative and postoperative change in the CPS was compared with the subjective visual improvement as assessed by a questionnaire. RESULTS: The postoperative improvement of FVA was statistically significant in eyes with mCNV (P =.010) but not significant in eyes with AMD (P =.495). The postoperative improvement of CPS was statistically significant both in eyes with AMD (P =.027) and in eyes with mCNV (P =.004). The subjective visual improvement was significantly correlated with the change of CPS in patients after a second better eye surgery. CONCLUSIONS: After macular translocation with 360-degree retinotomy, the improvement of reading ability was significant in eyes with both AMD and mCNV. We conclude that this surgical method is well suited to improve reading ability of patients with AMD or mCNV.     

Functional improvement after vision rehabilitation in low monocular vision after myopic macular degeneration and retinal detachment

PURPOSE: We present a case of a 62 year-old woman, with a single eye functional vision (VA of 0.16) who improved her vision after following a vision rehabilitation program, which included optical and non-optical devices for daily performance. CONCLUSIONS: A correct optometric evaluation and a training program are key factors to improve quality of life in low vision patients, whose ocular pathology allows no other treatment.